Validation of a simple clinical tool for screening of acute lacunar stroke-A substudy of the WAKE-UP trial

Francesco Arba; Chiara Rinaldi; Märit Jensen; Matthias Endres; Jochen B Fiebach; Robin Lemmens; Keith W Muir; Norbert Nighoghossian; Salvador Pedraza; Claus Z Simonsen; Vincent Thijs; Christian Gerloff; Joanna M Wardlaw; Götz Thomalla

doi:10.1177/17474930241253987

Validation of a simple clinical tool for screening of acute lacunar stroke-A substudy of the WAKE-UP trial

Int J Stroke. 2024 May 17:17474930241253987. doi: 10.1177/17474930241253987. Online ahead of print.

Authors

Francesco Arba¹, Chiara Rinaldi², Märit Jensen³, Matthias Endres^{4

5

6

7

8}, Jochen B Fiebach⁵, Robin Lemmens^{9

10}, Keith W Muir¹¹, Norbert Nighoghossian^{12

13}, Salvador Pedraza¹⁴, Claus Z Simonsen¹⁵, Vincent Thijs¹⁶, Christian Gerloff³, Joanna M Wardlaw¹⁷, Götz Thomalla³

Affiliations

¹ Stroke Unit, Careggi University Hospital, Florence, Italy.
² NEUROFARBA Department, University of Florence, Florence, Italy.
³ Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
⁴ Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.
⁵ Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.
⁶ German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.
⁷ German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.
⁸ German Center for Mental Health (DZPG), Partner Site Berlin, Berlin, Germany.
⁹ VIB Center for Brain & Disease Research, Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium.
¹⁰ Department of Neurology, University Hospitals Leuven, Leuven, Belgium.
¹¹ Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK.
¹² Department of Stroke Medicine, Université Claude Bernard Lyon, Lyon, France.
¹³ Hospices Civils de Lyon, Lyon, France.
¹⁴ Department of Radiology, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain.
¹⁵ Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
¹⁶ Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
¹⁷ Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK.

PMID: 38676549
DOI: 10.1177/17474930241253987

Abstract

Introduction: Lacunar stroke represents around a quarter of all ischemic strokes; however, their identification with computed tomography in the hyperacute setting is challenging. We aimed to validate a clinical score to identify lacunar stroke in the acute setting, independently, with data from the WAKE-UP trial using magnetic resonance imaging.

Methods: We analyzed data from the WAKE-UP trial and extracted Oxfordshire Community Stroke Project (OCSP) classification. Lacunar score was defined by National Institutes of Health Stroke Scale (NIHSS) < 7 and OCSP lacunar syndrome. Assessment of lacunar infarct by two independent investigators was blinded to clinical data. We calculated sensitivity, specificity, negative and positive predictive value (NPV and PPV, respectively) of lacunar score.

Results: We included 503 patients in the analysis, mean (±SD) age 65.2 (±11.6) years, 325 (65%) males, median (IQR) NIHSS = 6 (4-9); 108 (22%) lacunar infarcts were identified on magnetic resonance (MR), patients fulfilling lacunar score criteria were 120 (24%), of which 47 (44%) had a lacunar infarct. Lacunar score was negative in 322 (82%) of patients without lacunar infarct. Patients with lacunar score had lower NIHSS (4 vs 7, p < 0.001), higher systolic (157 vs 151 mmHg, p = 0.001) and diastolic (86 vs 83 mmHg, p = 0.013) blood pressure and smaller infarct volume (2.4 vs 9.5 mL, p < 0.001). Performance of lacunar score was as follows: sensitivity 0.44; specificity 0.82; PPV 0.39; NPV 0.84; and accuracy 0.73. Assuming a prevalence of lacunar stroke of 13%, PPV lowered to 0.30 but NPV was 0.90. Lacunar score performed better for supratentorial lacunar infarcts.

Conclusion: Lacunar score had a very good specificity and NPV for screening of lacunar stroke. Implementation of this simple tool into clinical practice may help hyperacute management and guide patient selection in clinical trials.

Data access statement: Data supporting the results of this paper are available upon reasonable request to the corresponding author.

Keywords: Lacunar stroke; Oxfordshire Community Stroke Project; acute ischemic stroke; diagnostic accuracy; early identification; emergency department; lacunar infarct; screening.